BNF for Children 2011-2012

162 3.5 Respiratory stimulants and pulmonary surfactants BNFC 2011–20123 Respiratory systemTracheal intubation may be necessary. In some childrenwith laryngeal oedema, adrenaline 1 in 1000 (1 mg/mL)solution may be given by nebuliser. However, nebulisedadrenaline cannot be relied upon for a systemic effect—intramuscular adrenaline should be used.Hereditary angioedema The administration of C1-esterase inhibitor (in fresh frozen plasma or in partiallypurified form) may terminate acute attacks of hereditaryangioedema, but is not practical for long-term prophylaxis;it can also be used for short-term prophylaxisbefore surgery or dental procedures [unlicensed indication].Tranexamic acid (section 2.11) is used for shorttermor long-term prophylaxis of hereditary angioedema;short-term prophylaxis is started several daysbefore planned procedures which may trigger an acuteattack of hereditary angioedema (e.g. dental work) andcontinued for 2–5 days afterwards. Danazol [unlicensedindication, see BNF section 6.7.2] is best avoided inchildren because of its androgenic effects but it can beused for short-term prophylaxis of hereditary angioedema.C1-ESTERASE INHIBITORCautions vaccination against hepatitis A (p. 607) andhepatitis B (p. 608) may be requiredPregnancy manufacturer advises avoid unless essentialBreast-feeding manufacturer advises use only ifpotential benefit outweighs risk—no informationavailableSide-effects rarely injection-site reactions, hypersensitivityreactions (including anaphylaxis)Licensed use not licensed for short-term prophylaxisof hereditary angioedemaIndication and doseAcute attacks of hereditary angioedema, shorttermprophylaxis of hereditary angioedemabefore surgery or dental procedures. By slow intravenous injection or intravenousinfusion (specialist use only)Neonate 20 units/kgChild 1 month–18 years 20 units/kgBerinert c (CSL Behring) TAInjection, powder for reconstitution C1-esteraseinhibitor, net price 500-unit vial = £550.00Electrolytes Na + 2.1 mmol/10 mL-vial3.5 Respiratory stimulantsand pulmonarysurfactants3.5.1 Respiratory stimulants3.5.2 Pulmonary surfactants3.5.1 Respiratory stimulantsRespiratory stimulants (analeptic drugs), such as caffeine,reduce the frequency of neonatal apnoea, and theneed for mechanical ventilation during the first 7 days oftreatment. They are typically used in the managementof very preterm neonates, and continued until a postmenstrualage of 34 to 35 weeks is reached (or longer ifnecessary). They should only be given under expertsupervision in hospital; it is important to rule out anyunderlying disorder, such as seizures, hypoglycaemia, orinfection, causing respiratory exhaustion before startingtreatment with a respiratory stimulant.Caffeine (as caffeine base) is licensed for the treatmentof apnoea in preterm neonates; it is used in preferenceto theophylline (section 3.1.3). Caffeine has feweradverse effects and a longer half-life than theophyllinein neonates. It is well absorbed when given orally;intravenous treatment is rarely necessary. Plasma-caffeineconcentration should be measured if the child haspreviously been treated with theophylline. The therapeuticrange for plasma-caffeine concentration is usually10–20 mg/litre (50–100 micromol/litre), but a concentrationof 25–35 mg/litre (130–180 micromol/litre)may be required.CAFFEINECautions gastro-oesophageal reflux; cardiovasculardisease; monitor plasma-caffeine concentration (seenotes above); monitor closely for 1 week after stoppingtreatmentSide-effects hypertension, tachycardia; irritability,restlessness; hypoglycaemia, hyperglycaemia; fluidand electrolyte imbalanceIndication and doseNoteDose expressed as caffeine baseNeonatal apnoea. By mouth, expressed as caffeine baseNeonate initially 10 mg/kg, then 2.5–5 mg/kgonce daily starting 24 hours after initial dose. By intravenous infusion, expressed as caffeinebaseNeonate initially 10 mg/kg over 30 minutes, then2.5–5 mg/kg over 10 minutes once daily starting24 hours after initial doseSafe practiceWhen prescribing, always state dose in terms of caffeinebaseCaffeine base 1 mg = caffeine citrate 2 mgAdministration caffeine injection may be administeredby mouth or by intravenous infusionCaffeine (Non-proprietary) AInjection, caffeine 5 mg/mL, net price 1-mL amp =£4.89Electrolytes Na + < 0.5 mmol/amp3.5.2 Pulmonary surfactantsPulmonary surfactants derived from animal lungs,beractant and poractant alfa are used to prevent andtreat respiratory distress syndrome (hyaline membranedisease) in preterm neonates. Prophylactic use of apulmonary surfactant may reduce the need for mechanicalventilation and is more effective than ‘rescue treat-